Benefits: What is Medicare?

Benefits: What is Medicare?

What is Medicare?

Medicare is a federally-funded health insurance program that provides coverage to:

  • Individuals who are 65 years old or older;
  • Individuals who qualify for Social Security Disability Insurance benefits based on disability (SSDI);
  • Individuals with end-stage renal disease (ESRD).

The Social Security Administration (SSA) processes Medicare applications and collects Medicare premiums. Centers for Medicare and Medicaid Services (CMS) administer all other aspects of the Medicare program.

Medicare consists of four different parts: Part A, Part B, Part C,and Part D.

Medicare Enrollment

Individuals eligible for Social Security benefits (SSDI), Child Disability Benefits (CDB), Disabled Widowers’ Benefits (DWB) are automatically eligible for Medicare after they have been eligible for cash benefits for 24 months.

Individuals with ALS or end-stage renal disease do not have to wait for 24 months.

How to Enroll in Medicare

Individuals eligible for Medicare may enroll online or at their local SSA office.

There are penalties for late enrollment into Medicare Part B (10% for each 12 month period the person could have had Part B but did not sign up for it). Exceptions may apply in certain situations. If you are not sure whether you are eligible for Medicare or have other questions about enrollment you can consult an advocate from a Medicare Advocacy Project (MAP) or a counselor from SHINE (see below).

You can find out more about Medicare enrollment here.

Medicare Part A

Medicare Part A, also known as The Hospital Insurance (HI) Program, pays for inpatient hospital treatment, post-hospital extended care including skilled nursing home care, and hospice care for terminally ill. Custodial long-term nursing home care is not covered under Part A.

Medicare beneficiaries must pay deductibles and coinsurance for their Part A benefits. There is no monthly premium associated with Medicare Part A.

You can get more information about Medicare Part A here.

Medicare Part B

Medicare Part B, also known as Supplementary Medical Insurance, pays for physician and diagnostic services, outpatient hospital care, physical therapy, ambulance services, medical equipment, prosthetic devices, and certain other services not covered under Part A.

Each person enrolled in Part B must pay 25 percent of the plan’s cost through a monthly premium. SSA automatically deducts Part B premiums from the Social Security Disability Insurance (SSDI) cash benefits. The federal government pays for the rest of the medical costs under Part B.
Certain low-income individuals who have Medicare and MassHealth may be eligible for help with Medicare premiums. Click here to read more.

You can get more information about Medicare Part B here.

Medicare Part C

Medicare Part C, also known as Medicare Advantage, pays for medical services that people receive through health maintenance organizations (HMO), Preferred Provider Organizations (PPO), Special Needs Plans (SNP), or Private Fee-For-Service Plans (PFFSP). Individuals who enroll in any of these plans will get coverage for the same services covered under Medicare Part A and Part B.

You can get more information about Medicare Part C here.

Medicare Part D

Medicare Part D covers the cost of prescription medications for individuals enrolled in private insurance plans approved by the Centers for Medicaid and Medicare (CMS). There are two ways to get Medicare prescription drug coverage:

  1. Medicare Prescription Drug Plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
  2. Medicare Advantage Plans (HMO or PPO) are Medicare health plans that offer Medicare prescription drug coverage in addition to payments for other medical services. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D) through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called "MA-PDs."

Each private health insurance plan has different rules about the cost and conditions of drug coverage. People who are eligible for Medicare and MassHealth, and some other low income beneficiaries, qualify for the Extra Help program, which pays for up to 95% of their Medicare prescription drug costs.

Extra Help and other programs (such as Medicare Savings Programs) can make your health care and prescription drug costs more affordable. To find and compare plans in your area use the Medicare Plan Finder or contact MAP or SHINE advocates who can help you find the plan that is best for you. You can also enroll into a Part D Medicare plan by calling 1-800-MEDICARE (1-800-633-4227).

It is important to choose and sign up for a Medicare Part D plan as soon as you are eligible for coverage. If you decide not to join a Medicare drug plan when you are first eligible and you don’t have other creditable prescription drug coverage, you will likely pay a late enrollment penalty.

What are the basic rights of Medicare beneficiaries?

Medicare beneficiaries have the right:

  • To receive emergency care in any situation where the beneficiary has severe pain, an injury, or a sudden illness that may cause serious danger without immediate medical care;
  • To appeal decisions about payment or services;
  • To receive information from the health care provider about different treatment options;
  • To receive clear and simple explanations of the benefits available under Medicare, the limitations on payments (including deductible and coinsurance), and a description of the limited benefits for long-term care services available under Medicare plans.

Medicare Termination

For SSDI beneficiaries under the age of 65, Medicare coverage may terminate if SSA makes a determination that the individual is no longer disabled under SSA rules.

Additional Sources of Information